India’s healthcare system stands at an inflection point. Guided by the vision of Viksit Bharat 2047, the nation is advancing toward a future where care is accessible, affordable, and accountable for every citizen. Over the past decade, rising insurance coverage and expanding digital infrastructure have strengthened access and trust. Yet these gains remain fragile unless Fraud, Waste, and Abuse (FWA) are brought firmly under control.
Each year, an estimated ₹8,000–10,000 crore of claim payouts leak through FWA which erode insurer margins, inflate customer premiums, and strain public resources. The impact runs deeper than financial leakage alone: delayed settlements, reduced trust, and hesitation around product innovation all weaken the foundation of India’s health insurance ecosystem.
At the root of the challenge lie systemic and behavioral gaps—fragmented data, weak controls, misaligned incentives, and uneven protocols. These weaknesses create predictable leak paths and perpetuate a cycle of rising claim costs, higher premiums, and growing out-of-pocket (OOP) expenditure.
The report outlines a national roadmap to reform India’s health insurance sector through a three-pillar strategy—Prevention, Detection, and Deterrence—underpinned by the foundational enablers of standardization, AI-driven automation, and seamless real-time data interoperability.
- Build a unified codebook and tariff framework to eliminate pricing inconsistencies and enable fair adjudication.
- Apply AI to automate checks, anomaly scoring, ICD mapping, and fraud prediction for faster, accurate claim decisions.
- Integrate telehealth, remote monitoring, and digital records via ABDM/NHCX to reduce duplicate claims and waste.
- Introduce provider and member trust scoring to influence claim routing, approval speed, and pricing transparency.
- Codify insurance fraud under law with clear penalties and investigation processes to ensure accountability.
- Enforce real-time, bidirectional data exchange across all stakeholders via ABDM, NHCX, and standardized APIs.
The report calls on insurers, TPAs, providers, and policymakers to jointly embed integrity, transparency, and intelligence into the health financing system. If implemented at scale, the roadmap could reduce FWA leakage to under 1% by 2047, laying the foundation for a resilient, inclusive, and tech-driven health insurance future.